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NeurologyMain91-100Q91A26-year-oldwomancomestotheemergencydepartmentwithnumbnessandweaknessofbothlegs.Throughoutthepriorday,shefeltlikeherlegskeptgoingtosleepandonwakingthismorning,shehaddifficultystandingupandwalking.Shealsoreportsurinaryurgencyand2episodesofinvoluntaryurineleakage.Thepatienthasnohistoryofbackpainortrauma.Fouryearsago,shewasdiagnosedwithtype1diabetesmellitus;andherglycemiccontrolismaintainedbycontinuoussubcutaneousinsulininfusionpump.Oneyearago,shewasevaluatedforrighteyepainandimpairedvision,buttheseresolvedspontaneouslyinaweek.Temperatureis36.9C(98.4F),bloodpressureis134/78mmHg,andpulseis76/min.Visualacuityandpupillaryreflexesarenormal.Musclestrengthintherightandleftlowerextremitiesare3/5and4/5frespectively.Patellarreflexesare3+onbothsides,andplantarreflexesareupgoing.Sensationtovibration,lighttouch,andpainisdecreasedinbothlegs.Herfingerstickglucoselevelis144mg/dL.Whichofthefollowingisthemostlikelycauseofthispatient'scurrentsymptoms?A.AnteriorcerebralarteryocclusionB.DiabeticpolyneuropathyC.Guillain-BarresyndromeD.MultiplesclerosisE.ParasagittalmeningiomaF.VitaminB12deficiencyA91Correctanswer:DThispatientlikelyhasmultiplesclerosis(MS)ranautoimmuneinflammatorydemyelinatingdisorderofthecentralnervoussystem(CMS)thattypicallypresentswithneurologicdeficitsdisseminatedinspaceandtimeinwomenage15-50.MSshouldbesuspectedinpatientswith2distinctiveepisodesofCNSdysfunctionwithatleastsomeresolutionthatcannotbeexplainedbyasinglelesion.Symptomsoccuroverhourstodaysandthenimproveoverweekstomonths,althoughsomemaybepermanent.Commoninitialsymptomsmayinclude:1.Opticneuritis:monocularvisualloss,painfuleyemovements,andafferentpupillarydefect2.Transversemyelitis:motorandsensorylossbelowthelevelofthelesionwithbowelandbladderdysfunction.Patientsinitiallyhaveflaccidparalysis(spinalshock),followedbyspasticparalysiswithhyperreflexia.3.Internuclearophthalmoplegia:demyelirtationofthemediallongitudinalfasciculusresulting]nimpairedconjugatehorizontalgazeinwhichtheaffectedeye(ipsiiateraltothelesion)isunabletoadductandthecontralateraleyeabductswithnystagmus4.Cerebellardysfunction:intentiontremor,ataxia,andnystagmus(ChoiceA)Thisyoungpatientwithoutcardiovascularriskfactorsisunlikelytohavehadastroke.Inaddition,anteriorcerebralarteryocclusionwouldleadtoacute-onsetcontralaterallegweakness.(ChoiceB)Diabeticpolyneuropathycausessymmetricsensorylossinastocking-glove”distribution.Itoccursinsidiously,approximately5yearsafteradiagnosisoftype1diabetesmellitus,andcanhaveassociateddecreased/absentanklereflexesinitiallywithprogressiontoinvolveotherreflexes.Severecasesmaybeassociatedwithmuscleweakness.(ChoiceC)Guillain-Barresyndromeleadstorapidlyprogressiveascendingmuscleparalysisgenerallyprecededbyinfection(eg,Campylobacterjejuni,viruses).Associatedsymptomsoftenincludereduced/absentreflexesandparesthesias.Opticneuritisisnotcharacteristic,(ChoiceE)Asymptomaticparasagittalmeningiomawouldlikelycauseprogressiveneurologicdeficits(eg,bilaterallowerextremityweakness/numbness)andseizureduetogrowthandcompressionoflocalizedbrainstructures.Patientsmayalsodevelopsymptomsofelevatedintracranialpressure(eg;headache,nausea/vomiting).(ChoiceF)VitaminB12deficiencyoccursduetolong-standingpoorabsorption(egfperniciousanemia,Crohndisease)orlackofdietaryanimalproducts(egrvegandiet).Patientstypicallydevelopsubacutecombineddegenerationofthespinalcordleadingtoprogressivesymmetricsensoryloss/paresthesias,sensoryataxia,andspasticmuscleweakness.Educationalobjective:Multiplesclerosisshouldbesuspectedinyoungwomenwithneurologicdeficitsdisseminatedinspaceandtime.Commonpresentationsincludeopticneuritis(eg,monocularblindness,painfuleyemovement)andtransversemyelitis(eg,motorandsensorylossbelowthelevelofthelesion,incontinence).Q92A32-ye3r-oldwomancomestotheofficewithsevereldaysoftinglingandnumbnessinbothhands.ShemovedtoArizonainJunetocareforherailingmotherwhodied2weeksagoofmetastaticlungcancer.Sincemoving:shehashadoccasionalheadaches,dizziness,fatigue,poorsleep,andblurryvision.Shehashadnofevers,weightloss,oranorexia.Hermedicalhistoryisunremarkable.Thepatientdrinks1or2glassesofwinedailybutdoesnotusetobaccoorillicitdrugs.Herbloodpressureis132/70mmHgandpulseis78/min.Sensationtolighttouchandpainisdecreaseddistallyinthebilateralupperextremities.Musclestrengthis5/5intheupperandlowerextremitiesanddeeptendonreflexesarenormal.Onfunduscopicexamination,therightopticdiscappearshyperemicandswollen.Whichofthefollowingisthebestnextstepinmanagementofthispatient?A.CarotidDopplerultrasoundB.Cervicalspinex-rayC.LumbarpunctureD.MRIofthebrainandspineE.NerveconductionstudiesF.SerumimmunoglobulinlevelsG.TrialoflorazepamA92Correctanswer:DThispatientlikelyhasmultiplesclerosis(MS),anautoimmuneinflammatorydemyeiinatingdisorderofthecentralnervoussystem(CNS)thattypicallypresentswithneurologicdeficitsdisseminatedinspaceandtime(eg,sensoryloss/paresthesiasoftheextremities,dizziness,opticneuritis)jnwomenage15-50.Symptomsmayworsenduringexposuretohightemperatures：suchasmovingtoArizonainJune(Uhthoffphenomenon)